Typical work ups

[MSUSpartan642]

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Wondering if there is any quick guide or hand book for general orders/work ups for common complaints in EM. I'm a new intern and I find myself putting in orders but I seem to forget parts from time to time. Thanks for any help, just trying to make this transition a bit smoother from med student to intern.

 

[e30ftw]

wikem (phone app), pocket EM (small book), emedicine (website) all have this stuff.

look up and read ACEP clinical policy or good review articles on emergent work up of cp/ha/cva/abdpain etc.

your ED EMR should have "profiles" that will point you in the right direction.

never do something you're really not sure of, because chances are at this stage you'll be wrong. Ask someone (resident/attending).

order progressively more stuff the older the patient is.. progressively less if they are dnr/young.

when all else fails, look up their prior ED visits/admissions and look at what was ordered then.

 

[namethatsmell]

Wondering if there is any quick guide or hand book for general orders/work ups for common complaints in EM. I'm a new intern and I find myself putting in orders but I seem to forget parts from time to time. Thanks for any help, just trying to make this transition a bit smoother from med student to intern.

EMRA Basics of EM.

There's an app form too.

 

[TooMuchResearch]

wikem (phone app), pocket EM (small book), emedicine (website) all have this stuff.

look up and read ACEP clinical policy or good review articles on emergent work up of cp/ha/cva/abdpain etc.

your ED EMR should have "profiles" that will point you in the right direction.

never do something you're really not sure of, because chances are at this stage you'll be wrong. Ask someone (resident/attending).

order progressively more stuff the older the patient is.. progressively less if they are dnr/young.

when all else fails, look up their prior ED visits/admissions and look at what was ordered then.

DNR is not the same as "do not work up or treat." DNR is "if dead, leave dead. If not dead, this does not apply."

 

[WilcoWorld]

In residency I used the Tintinalli handbook for common stuff an UpToDate.com for less common stuff. That being said, nothing substitutes for individualized work ups (if the patient had 3 abdominal CT's since September, you probably shouldn't order a new one for the same epigastric pain, but it the patient's chest pain has been "ruled out" with a single set of enzymes 3 times, than you might want to push for more testing this time).

 

[e30ftw]

DNR is not the same as "do not work up or treat." DNR is "if dead, leave dead. If not dead, this does not apply."

very interesting thank you for clarifying...

 

[TrumpetDoc]

DNR is not the same as "do not work up or treat." DNR is "if dead, leave dead. If not dead, this does not apply."

Need to print and post for all ED nurses in all ED break rooms...and smoking areas 😉


Thumb typed from iPhone using Tapatalk

 

[Apollyon]

As I am prone to say, "a 'DNR' is NOT a 'do not treat'. We won't just put Mom in the corner and let her wither".

 

[WilcoWorld]

OK - I'm going to attempt to further derail this thread with a question.

DNR does not mean do not treat, but how do you approach hospice patients. Here is a case I had recently:

Pt on hospice for widely metastatic cancer presents with significant dyspnea. He's so SOB that he won't get out of his wheelchair, as it provides the bracing for his tripod-breathing. Without any testing other than H&P, you strongly suspect a large pericardial effusion as the cause of his symptoms. It's the middle of the day, and you could get IR to place a drain with a couple of phone calls.

What do you do?

 

[Apollyon]

OK - I'm going to attempt to further derail this thread with a question.

DNR does not mean do not treat, but how do you approach hospice patients. Here is a case I had recently:

Pt on hospice for widely metastatic cancer presents with significant dyspnea. He's so SOB that he won't get out of his wheelchair, as it provides the bracing for his tripod-breathing. Without any testing other than H&P, you strongly suspect a large pericardial effusion as the cause of his symptoms. It's the middle of the day, and you could get IR to place a drain with a couple of phone calls.

What do you do?

Draining the effusion would be therapeutic, and not incongruent with the hospice goals. At the same time, you can say that this likely will lead to his death, and that you can give him more pain meds to make his SOB less uncomfortable. What if it is a PE, though? Different story (in that no, I wouldn't tPA).

 

[WilcoWorld]

Draining the effusion would be therapeutic, and not incongruent with the hospice goals. At the same time, you can say that this likely will lead to his death, and that you can give him more pain meds to make his SOB less uncomfortable. What if it is a PE, though? Different story (in that no, I wouldn't tPA).

Exactly my point - it's in line with comfort care, but is also invasive and fraught with potential complications. Also, the differential is pretty big (PE, pleural effusion, pneumonia, tumor compressing upper airway, etc…).

 

[turkeyjerky]

Draining the effusion would be therapeutic, and not incongruent with the hospice goals. At the same time, you can say that this likely will lead to his death, and that you can give him more pain meds to make his SOB less uncomfortable. What if it is a PE, though? Different story (in that no, I wouldn't tPA).

I think you meant that draining the effusion would be palliative, right? Although, obviously, it's therapeutic as well, to a certain extent.

I'd discuss it with the patient and/or the family, and offer drainage vs symptomatic control w/ opioids. If the patient doesn't have the mental status to participate and surrogate decision makers aren't available, I'd treat symptomatically w/ morphine and allow the patient to expire.

 

[Apollyon]

I think you meant that draining the effusion would be palliative, right? Although, obviously, it's therapeutic as well, to a certain extent.

I'd discuss it with the patient and/or the family, and offer drainage vs symptomatic control w/ opioids. If the patient doesn't have the mental status to participate and surrogate decision makers aren't available, I'd treat symptomatically w/ morphine and allow the patient to expire.

Well, I believe therapeutic and palliative to be synonymous, in this case (as the 'therapeutic' is vis-a-vis 'diagnostic'). If there is a difference, I am not aware of it.

 

[DeadCactus]

Going back to the original topic, I think you're approaching this from the wrong angle. The question shouldn't be what tests get ordered for each chief complaint. The process should be Chief Complaint -> What life threats can cause this symptom? -> What have I adequately ruled out or in with history and physical exam? -> What tests do I need to order to evaluate the remaining life threats?

The two remaining considerations are what treatments do I need to order and what work-up is warranted in the ED for conditions you do diagnose.

I get where you're coming from with the question but I feel like it's a mistake to jump straight to ordering panels based on Chief Complaint by memorizing work-ups. You're going for efficiency and making sure you order the right tests all at the start but as an intern I think you should be taking your time to think through the work-up and learning the "panels" naturally through repetition...

 

[TooMuchResearch]

As I am prone to say, "a 'DNR' is NOT a 'do not treat'. We won't just put Mom in the corner and let her wither".

Unfortunately it gets interpreted as do not treat, even by residents and staff. I saw it happen multiple times as a med student. Hasn't come up as a resident, yet, though in conference multiple residents have mentioned that a patient's DNR status affects their decision to treat. Our main hospital's palliative care group has been trying to properly reeducate people.